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Fertility-preserving measures are becoming important for patients receiving oncological treatment. One method involves cryopreservation of ovarian tissue and transplanting it when treatment is completed. We report complications resulting from surgical and fertility medicine, and the results of procedures for the removal and transplantation of ovarian tissue carried out within the FertiProtekt network. A survey using a structured questionnaire was conducted among the FertiProtekt network centres between November 2015 and June 2016. The analysis included surgical techniques used to remove and transplant ovarian tissue, surgical complications and results. Laparoscopic removal and transplantation of ovarian tissue have a low risk of complications. Surgical complications occurred in three of the network's 1373 ovarian tissue removals (n = 1302) and transplantations (n = 71); two complications (0.2%) occurred during removal and one during transplantation. Menstruation resumed in 47 out of 58 women (81%) who underwent ovarian tissue transplantation. Hormonal activity occurred in 63.2% of transplantations with a follow-up of 6 months or over. Sixteen pregnancies occurred in 14 patients, with nine births. The risks and complications of removal and transplantation of ovarian tissue are similar to those of standard laparoscopy. These procedures are becoming standard for fertility protection in cancer patients., (Copyright © 2017 Reproductive Healthcare Ltd. Published by Elsevier Ltd. All rights reserved.)

Purpose: Most guidelines about fertility preservation are predominantly focused on scientific evidence, but are less practically orientated. Therefore, practically oriented recommendations are needed to support the clinician in daily practice., Methods: A selective literature search was performed based on the clinical and scientific experience of the authors, focussing on the most relevant diseases and gynaecological cancers. This article (Part I) provides information on topics that are essential for the fertility preservation indication, such as disease prognosis, disease therapy and its associated risks to fertility, recommending disease-specific fertility preservation measures. Part II specifically focusses on fertility preservation techniques., Results: In breast cancer patients, fertility preservation such as ovarian tissue and oocyte cryopreservation is especially recommended in low-stage cancer and in women < 35 years of age. In Hodgkin's lymphoma, the indication is mainly based on the chemotherapy regime as some therapies have very low, others very high gonadotoxicity. In borderline ovarian tumours, preservation of fertility usually is achieved through fertility sparing surgery, ovarian stimulation may also be considered. In cervical cancer, endometrial cancer, rheumatic diseases and other malignancies such as Ewing sarcoma, colorectal carcinoma, non-Hodgkin lymphoma, leukaemia etc., several other factors must be considered to enable an individual, stage-dependent decision., Conclusion: The decision for or against fertility preservation depends on the prognosis, the risks to fertility and individual factors such as prospective family planning.

Study Question: What is the success rate in terms of ovarian activity (menstrual cycles) as well as pregnancy and delivery rates 1 year after orthotopic ovarian transplantations conducted in a three-country network?, Summary Answer: In 49 women with a follow-up >1 year after transplantation, the ovaries were active in 67% of cases and the pregnancy and delivery rates were 33 and 25%, respectively., What Is Known Already: Cryopreservation of ovarian tissue in advance of cytotoxic therapies and later transplantation of the tissue is being performed increasingly often, and the total success rates in terms of pregnancy and delivery have been described in case series. However, published case series have not allowed either a more detailed analysis of patients with premature ovarian insufficiency (POI) or calculation of success rates based on the parameter 'tissue activity'., Study Design, Size, Duration: Retrospective analysis of 95 orthotopic transplantations in 74 patients who had been treated for cancer, performed in the FertiPROTEKT network from 2008 to June 2015. Of those 95 transplantations, a first subgroup (Subgroup 1) was defined for further analysis, including 49 women with a follow-up period >1 year after transplantation. Of those 49 women, a second subgroup (Subgroup 5) was further analysed, including 40 women who were transplanted for the first time and who were diagnosed with POI before transplantation., Participants/materials, Setting, Methods: Transplantation was performed in 16 centres and data were transferred to the FertiPROTEKT registry. The transplantations were carried out after oncological treatment had been completed and after a remission period of at least 2 years. Tissue was transplanted orthotopically, either into or onto the residual ovaries or into a pelvic peritoneal pocket. The success rates were defined as tissue activity (menstrual cycles) after 1 year (primary outcome) and as pregnancies and deliveries achieved., Main Results and the Role of Chance: The average age of all transplanted 74 women was 31 ± 5.9 years at the time of cryopreservation and 35 ± 5.2 at the time of transplantation. Twenty-one pregnancies and 17 deliveries were recorded. In Subgroup 1, tissue was cryopreserved at the age of 30 ± 5.6 and transplanted at 34 ± 4.9 years. Ovaries remained active 1 year after transplantation in 67% of cases (n = 33/49), the pregnancy rate was 33% (n = 16/49) and the delivery rate was 25% (n = 12/49). In Subgroup 5, tissue was cryopreserved at the age 30 ± 5.9 years and transplanted at 34 ± 5.2 years. Ovaries remained active 1 year after transplantation in 63% of cases (n = 25/40), the pregnancy rate was 28% (n = 11/40) and the delivery rate was 23% (n = 9/40). The success rates were age dependant with higher success in women who cryopreserved at a younger age. In Subgroup 5, tissue was exclusively transplanted into the ovary in 10% (n = 4/40) of women and into a peritoneal pocket in 75% (n = 30/40), resulting in spontaneous conceptions in 91% of patients (n = 10/11)., Limitations, Reasons for Caution: The data were drawn from a retrospective analysis. The cryopreservation and transplantation techniques used have changed during the study period. The tissue was stored in many tissue banks and many surgeons were involved, leading to heterogeneity of the procedures. However, this does reflect the realistic situation in many countries. Although patients with POI were evaluated before transplantation to allow specific analysis of the transplanted tissue itself, the possibility cannot be excluded that residual ovarian tissue was also reactivated., Wider Implications of the Findings: This is the largest case series worldwide to date and it confirms that cryopreservation and transplantation of ovarian tissue can be a successful option for preserving fertility. Persistent tissue activity 12 months after transplantation suggests that the pregnancy and delivery rates may increase further in the future. As transplantation into the peritoneum results in a high success rate, this approach may be an alternative to transplantation into the ovary. However, in order to establish the best transplantation site, a randomized study is required., Study Funding/competing Interest: This study was in part funded from the Deutsche Forschungsgemeinschaft (# DI 1525) and the Wilhelm Sander Foundation (2012.127.1) and did not receive any funding from a commercial company. No competing interests., Trial Registration Number: None., (© The Author 2016. Published by Oxford University Press on behalf of the European Society of Human Reproduction and Embryology. All rights reserved. For Permissions, please email: journals.permissions@oup.com.)

Objective: What are the patients attitudes about their fertility and about the counselling process at the time when fertility preservation counselling is performed?, Study Design: A survey regarding fertility concerns and counselling performance in relation to the chosen fertility preservation procedure such as no treatment, GnRH agonists, and freezing of ovarian tissue or oocytes/zygotes was prospectively conducted in four university centres and one private centre, all belonging to the network FertiPROTEKT in Germany and Switzerland., Results: All women (n=145) received a questionnaire at the first counselling appointment. The mean age of the patients was 30 years (±5.8, range 17-43 years). 91% were referred by their treating oncologists. Single patients preferred invasive strategies, such as freezing of oocytes/zygotes (44.3%) or freezing of ovarian tissue (36%), whereas only 19.7% opted for no treatment/GnRH agonists. In married couples, the proportions were 28.9%, 31.1% and 40.0% respectively. Women without children also opted more frequently for invasive strategies, such as freezing of oocytes/zygotes (84.5%) or freezing of ovarian tissue (74.1%), and less frequently for no treatment/GnRH agonists (63.3%). Physical and psychological status, current and future fertility concerns and satisfaction with the counselling process were equal in all treatment groups., Conclusion: As fertility concerns and attitudes about the counselling process were independent from the fertility preservation procedure chosen, the preferred treatment can hardly be predicted and therefore all women should be counselled about all possible fertility preservation techniques., (Copyright © 2016 Elsevier Ireland Ltd. All rights reserved.)

Background: Ovarian cancer is a rare disease especially in young patients and surgical treatment often leads to loss of fertility. This study investigated the incidence of the different histological types and discusses the possibility of fertility preservation., Patients and Methods: A retrospective analysis of patients with an ovarian tumour under the age of 40 who presented either to the Women's University Hospital, Tuebingen or to centres of the FertiPROTEKT network was performed., Results: Out of 51 patients with ovarian cancer from Tuebingen, 21 (41.2%) were eligible for fertility-preserving surgery, 11 received chemotherapy and from those 4 (36.4%) chose a fertility preservation technique. From the FertiPROTEKT network, 26/41 patients (63.4%) decided to undergo fertility preservation. No complications and postponement of chemotherapy due to fertility preservation procedures were noted., Conclusion: With careful consideration of the risks, the correct indication and diligent aftercare, the realisation of conception is possible also for patients with ovarian cancer., (Copyright© 2014 International Institute of Anticancer Research (Dr. John G. Delinassios), All rights reserved.)

Significant improvement in the survival rates of children with pediatric cancers has been achieved over the last 25 years, so the number of long-term survivors is increasing and their subsequent quality of life is of increasing importance. One of the most serious side effects of chemotherapy or radiotherapy is damage to the ovarian function, which can lead to loss of fertility. The degree of this damage depends on the substances used, the dose of radiotherapy reaching the ovaries, and the age of the girl at the time of treatment. Up to now, the only established method of fertility preservation has been cryoconservation of fertilized egg cells or embryos, but this is not possible in prepubertal girls because of their sexual immaturity. Removal of ovarian tissue and subsequent cryoconservation with the option of later orthotopic retransplantation is therefore an option to these girls. This method can lead to pregnancy and birth in adult women. Up to now there are no studies about the retransplantation of ovarian tissue which was removed before puberty. Displacement of the ovaries away from the radiation field before radiation to the pelvic area can be considered; however, the data is controversial. One problem in the use of fertility preservation methods in these very young patients is that they undergo procedures which, because of their age, they mostly do not understand and the parents must make a decision based on the assumed later wishes of their daughter., (Copyright © 2012 North American Society for Pediatric and Adolescent Gynecology. Published by Elsevier Inc. All rights reserved.)

Objectives: Despite new treatment options, some patients with systemic lupus erythematosus (SLE) need to be treated with the cytotoxic agent cyclophosphamide (CYC). Unlike malignant disease, there are no recommendations for ovarian protection in SLE. The clinical experience of the FertiPROTEKT network as well as recommendations after literature review will be presented in this paper., Methods: Retrospective analyses of counselling and treatment data from the FertiPROTEKT register with special respect to SLE patients under 40 years prior to planned CYC treatment., Results: A total of 2836 patients were advised prior to cytotoxic treatment in one of the FertiPROTEKT centres during January 2007 to November 2011. Of those, 68 patients (mean age 25 +/- 6.07 years) were counselled for severe SLE. Only five women did not make use of a fertility preservation method. Sixty-three patients (92.6%) decided in favour of a fertility preservation method. The largest proportion (91.2%) opted for treatment with a GnRH analogue. Ovarian tissue removal for cryoconservation was performed in 16 patients (25%). Stimulation therapy for cryoconservation of fertilized egg cells was performed in three patients (4.4%)., Conclusions: When counselling patients with SLE for fertility preservation one has to be aware of the disease-specific risks. According to the literature, a safe and effective option in SLE up to now has been the use of a GnRH analogue. Cryoconservation of ovarian tissue must still be seen as an experimental treatment, but as data on removal, cryoconservation, retransplantation and pregnancies are steadily rising, this presents a promising option for young SLE patients. Cryoconservation of oocytes must be very critically evaluated due to the need for a stimulation therapy and should only be performed after particular consideration of the individual risks.

Objectives: Fertility preservation is not only important for malignant diseases but should also be offered to patients with autoimmune diseases (AID) like vasculitides, prior to cyclophosphamide therapy. No recommendations are available for patients with AID., Methods: Analysis from the Fertiprotekt registry of all female patients with age <40 and the diagnosis of a vasculitis. The number of counselled patients, their diagnosis and age, the number of children before the start of therapy as well as the fertility preservation treatment chosen were evaluated., Results: From January 2007 to November 2011, 47 patients with the diagnosis AID were counselled at 17 of the 69 Fertiprotekt centres. 80.9% decided for at least one of the offered preservation methods. Ovarian cryopreservation was performed in 6 patients, 36 patients opted for GnRH-analogue treatment. Two patients decided for a stimulation therapy for cryopreservation of oocytes., Conclusions: Regarding the experiences from the registry and the literature gonadotropin releasing hormone analogues are evaluated best and recommended to most of the patients with AID. Cryoconservation of ovarian tissue is a promising option. Stimulation for oocyte cryopreservation can be offered to patients with vasculitis. A combination of the methods might have the biggest preservative effect.